Disease trajectories in childhood atopic dermatitis: an update and practitioner's guide

Abstract

SummaryBackgroundAtopic dermatitis (AD) is a heterogeneous disease with a multifactorial aetiology and complex pathophysiology. This heterogeneity translates into different trajectories of disease progression with respect to severity, persistence and risk of development of atopic comorbidities. Determining which possible disease trajectories or comorbidities any individual child might develop is challenging in clinical practice. Tools that help identify paediatric patients at higher risk of disease progression would greatly aid clinicians.MethodsWe reviewed recent cohort studies to synthesize and simplify the epidemiological data to try to identify shared clinically relevant characteristics that may help physicians estimate the risk of disease progression in paediatric patients with AD.ResultsDespite the variability in data collection and methods of analysis and their limitations, there are common patterns of early‐childhood AD that may aid in the estimation of risk for disease progression. Factors associated with risk of AD progression include younger age of onset, family history of atopy, greater AD severity, filaggrin mutations, urban environment and polysensitization and/or allergic multimorbidity. Based on these factors, we provide a practitioner's guide for identifying, counselling and/or referring infants and children with AD at potentially higher risk of developing persistent AD and atopic comorbidities. We also present clinical scenarios to illustrate how these data relate to real‐life situations.ConclusionsUseful insights are provided for physicians and patients to inform them better about the risk of AD progression and to help guide care pathways for the paediatric population with AD. What's already known about this topic? The complex pathophysiology of atopic dermatitis (AD) translates into a heterogeneous clinical presentation and trajectories of disease progression.Although the consensus is that most paediatric patients with AD will eventually ‘outgrow’ the disease or follow the longitudinal trajectory known as the ‘atopic march’, a significant proportion will develop persistent AD and/or other atopic conditions.No known factors conclusively predict the risk of progression or development of comorbidities. What does this study add? Recent analyses of data from large cohorts of paediatric patients with AD have suggested the existence of potentially discrete clusters of patients who present with relatively common AD phenotypes.These studies have shed some light onto the factors associated with risk of progression, which we review in this article.A practitioner's guide with clinical scenarios is provided to help identify patients at high risk of progression to determine whether a patient should be monitored and/or would require specialist referral.

Spontaneous resolution of atopic dermatitis incidental to participation in benralizumab clinical trial for severe, uncontrolled asthma: a case report

“…This case is notable in that the patient was enrolled in a clinical trial focused on a specific drug indication—severe, uncontrolled asthma with elevated blood eosinophil counts—but experienced dramatic resolution of symptoms for a different condition that may have a related mechanism of action. Evidence is increasing that the pathology of asthma, AD, and other diseases that are part of the so-called atopic march are a result of a self-reinforcing and progressive cascade of epithelial barrier dysfunction in the skin, gut mucosa, and respiratory mucosa, allowing increased penetration of allergens and microbes that elicit a systemic, T cell-mediated eosinophilic hyper-response [ 2 , 3 , 8 ]. Because this inappropriate eosinophilic response is characteristic of all of the atopic diseases, it is conceivable that treatments targeting the underlying T cell–eosinophil interaction could potentially show efficacy against more than one condition [ 2 – 6 ].…”

Contribution of Antigen-Processing Machinery Genetic Polymorphisms to Atopic Dermatitis

“…We revealed that the same polymorphism ( LMP2 rs1351383*A/A ) was associated with later age of diagnosis (and probably later disease onset) but simultaneously with higher disease severity. It is known that factors associated with risk of AD progression and severity include, inter alia, younger age of onset, family history of atopy, filaggrin mutations, urban environment and poly-sensitization and/or allergic multi-morbidity [ 30 ]. Therefore, our result seems to state somehow in opposition with the above-mentioned data and require further explanation.…”

Protocol for a prospective, observational, longitudinal study in paediatric patients with moderate-to-severe atopic dermatitis (PEDISTAD): study objectives, design and methodology

“…There are various disease trajectories in paediatric patients with AD, and clinical presentation varies with different ages of onset and development of comorbid atopic conditions 11 12. Hence, patients in this study will be recruited into three age cohorts (<2 years, ≥2–<6 years and ≥6–<12 years) and followed for 5 years.…”